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Anxious Behaviors in Dementia: A Caregiver’s Guide to Understanding and Responding

Anxiety in dementia is common and can show up as restlessness, pacing, repetitive questions, or a sudden urge to 'go home.' It often worsens in the late afternoon or evening, a pattern called sundowning. The person may not be able to tell you what’s wrong, but their behavior is a reaction to something—discomfort, confusion, or an unmet need. The good news is that with calm, practical steps, you can often reduce their distress and your own stress. This guide gives you concrete words to say, actions to take, and tools to try.

Key points

  • Anxiety in dementia is a reaction to something—discomfort, confusion, or environment—not a deliberate behavior.
  • Sundowning (worsening in late afternoon/evening) is common; prepare with calming activities and reduced stimulation.
  • Always check for physical causes (pain, hunger, infection) before assuming the behavior is 'just dementia.'
  • Your calm presence, soft voice, and gentle touch are the most powerful tools you have.
  • Never argue, restrain, or raise your voice—it will escalate anxiety.
  • Keep a journal to spot triggers and patterns, and share it with the doctor.

What Are Anxious Behaviors in Dementia?

Anxious behaviors are actions that signal a person with dementia is feeling scared, overwhelmed, or uneasy. They can happen at any time but are especially common in the late afternoon and evening, a phenomenon known as sundowning. These behaviors are not deliberate—they are the brain’s way of expressing distress when it can no longer process internal or external cues. Common signs include pacing back and forth, asking the same question over and over, fidgeting, following you from room to room, or saying things like 'I want to go home' or 'I need to see my mother.' The person may also become restless, irritable, or suddenly refuse care.

Why Does Anxiety Happen in Dementia?

The dementia itself damages parts of the brain that control emotions and impulse regulation, making it harder for the person to calm down or reason through feelings. But anxiety is almost always triggered by something specific. Common triggers include physical discomfort (pain, hunger, thirst, being too hot or cold), environmental overload (too much noise, bright lights, shadows, or too many people), a change in routine, or a feeling of being lost or unsafe. The person may also be reacting to your own stress—if you are tense, frustrated, or speaking sharply, they will pick up on your body language and become more anxious. As one expert puts it, 'When you observe a behavior, don’t go into behavior mode—go into reaction mode.' Ask yourself: What are they reacting to?

The Sundowning Connection

Sundowning is a specific pattern where anxiety and agitation increase as the day goes on, often starting around 3 or 4 PM and lasting into the night. It is most common in moderate to severe dementia. The brain’s internal clock becomes disrupted, and the person may feel more confused as daylight fades. Repetitive behaviors like pacing or asking the same question are very typical during sundowning. Understanding this pattern helps you prepare: you can plan calming activities for late afternoon, reduce stimulation, and keep the environment predictable.

General caregiving information, not medical advice. Check medications and major care changes with your clinician.

Step-by-step

  1. Pause and breathe first. Before you react, take a slow breath. Your calm presence is the most powerful tool. If you are tense, the person will sense it and become more anxious. Lower your voice, soften your face, and slow your movements.

  2. Look for the trigger. Ask yourself: Could they be hungry, thirsty, too hot, too cold, in pain, or needing the bathroom? Check for physical causes like a full bladder, constipation, or an infection (especially a urinary tract infection, which can suddenly worsen behavior). If the behavior is new or worse, a doctor visit may be needed to rule out illness.

  3. Reduce environmental noise and confusion. Turn off the TV, close the curtains to soften shadows, and dim harsh lights. Too many sounds at once can overwhelm the brain. If there are multiple people talking, ask them to be quiet or move to another room. Create a calm, simple space.

  4. Use a gentle, reassuring tone and simple words. Say something like: 'I see you are feeling worried. I am right here with you. You are safe.' Avoid asking 'Why are you anxious?'—they may not know. Instead, name what you see: 'You seem restless. Let’s sit together for a moment.'

  5. Offer a comforting activity that matches their energy. If they are pacing, walk with them slowly. If they are restless, give them something to do with their hands, like folding towels, sorting socks, or holding a soft object. If they are asking to go home, do not argue—instead, say 'Tell me about your home' and let them talk, or redirect to a pleasant memory.

  6. Check the clock. If it is late afternoon, expect sundowning and proactively start a calming routine earlier. Play soft music they enjoyed in the past, offer a warm drink (caffeine-free), or sit together and look at a photo album. Predictability reduces anxiety.

  7. Give a simple, positive choice to restore a sense of control. For example: 'Would you like to sit in the blue chair or the brown chair?' or 'Should we have a snack now or in ten minutes?' Avoid open-ended questions like 'What do you want to do?' which can overwhelm.

  8. Use a soothing touch or a familiar object. A gentle hand on the shoulder, a favorite blanket, or a stuffed animal can provide comfort. Some people respond well to a weighted blanket (check with a doctor first). The goal is to ground them in the present moment.

  9. If the anxiety escalates into agitation or aggression, prioritize safety. Step back, give them space, and do not corner them. Speak in a low, slow voice. If you feel unsafe, leave the room and call for backup (another family member or a neighbor). Never restrain or argue.

  10. After the episode, write down what happened. Note the time, what was happening before, what you tried, and what helped. This journal will help you spot patterns and share useful information with the doctor.

What not to do

  • Do not argue or try to reason. Saying 'You are at home, Mom' or 'There is no one to see' will only increase their confusion and distress. Instead, validate their feeling: 'I hear you want to go home. Tell me about your home.'

  • Do not raise your voice or show alarm. If you sound upset, the person will mirror your anxiety. Keep your tone low and steady, even if you feel frustrated inside. Your calm is contagious.

  • Do not corner, crowd, or restrain the person. This can trigger a fight-or-flight response and lead to aggression. Give them physical space and approach from the front, not from behind.

  • Do not ignore the behavior or assume it will pass on its own. Untreated anxiety can escalate into agitation, aggression, or a fall. Always try to address the underlying cause.

  • Do not use medications as a first response. Antipsychotics and sedatives have serious risks for people with dementia and should only be used after non-drug approaches have been tried and discussed with a doctor. Non-pharmacologic interventions are the mainstay of management.

  • Do not take the behavior personally. The anxiety is not about you—it is a symptom of the disease. Remind yourself: 'This is the dementia talking, not my loved one.'

Practical tools

  • The 'Go Home' Redirect Script

    When the person says 'I want to go home,' do not correct them. Instead, say: 'Tell me about your home. What was your favorite room?' or 'I miss home too. Let’s sit and look at some photos.' If they insist on leaving, offer a walk around the block or a short car ride, then return to a calm activity.

  • The Sundowning Prevention Kit

    Prepare a small basket or bag with calming items: a soft scarf or blanket, a favorite music playlist (on a simple device), a few familiar photos, a scented lotion (like lavender), and a snack like crackers or apple slices. Keep it in the living room and bring it out in the late afternoon.

  • The 'Check Your Own Body Language' Checklist

    Before you approach, quickly scan yourself: Are my shoulders tense? Is my jaw tight? Am I frowning? Take three slow breaths, relax your face into a soft smile, and lower your voice. Your body language can either calm or trigger the person.

  • The 5-Minute Pacing Walk

    If the person is pacing anxiously, join them. Walk slowly beside them, matching their pace. After a few minutes, gently guide them toward a chair or a window. Say 'Let’s rest here for a moment.' This uses their restless energy in a safe way.

  • The 'What’s Different?' Journal

    Keep a small notebook or a note on your phone. Each time anxiety spikes, write: time of day, what happened just before, what the person said or did, what you tried, and what helped. Over a week, patterns will emerge—like a certain time of day or a specific noise that triggers them.

  • The 'Yes, And...' Validation Phrase

    When the person says something anxious like 'I need to pick up the kids from school,' do not say 'No, the kids are grown.' Instead, say 'Yes, and they are safe. Let’s have a cup of tea while we wait.' This validates the feeling without reinforcing the false belief.

Discuss with your clinician

If the anxiety is new or suddenly worse, ask the doctor to check for a urinary tract infection, constipation, or other infection that could be causing the behavior.

If non-drug approaches are not working after several weeks, ask about whether a low-dose medication (like an antidepressant or a specific antipsychotic) might be appropriate, and discuss the risks and benefits.

If the person has Lewy body dementia, ask the doctor about which anxiety medications are safest, as some can worsen symptoms or cause severe side effects.

If the person is taking multiple medications, ask for a medication review to see if any could be contributing to anxiety or agitation.

If you feel overwhelmed or unsafe, ask about respite care, adult day programs, or in-home support services to give yourself a break.

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